Job description
InnovaCare Partners, LLC
InnovaCare Health has partnered with Ally HealthCare in providing primary care in the Temple Terrace area. Ally HealthCare is looking for a Clinical Social Worker to join their growing team.
Ally Healthcare is committed to providing compassionate and comprehensive care for all adults over the age of 18. Ally Healthcare strives for a holistic approach to medical care, by integrating physical and psychological factors with the values and beliefs of their patients.
Position Summary
Collaborates with the assigned clinical team to identify the most likely to benefit from care coordination services including assessing patients’ risk factors and the need for care coordination, clinical utilization management, and preventive care services.
Essential Functions
- Takes the lead in ensuring the continuity and consistency of care, across the continuum (inpatient, emergency, and ambulatory care/outpatient to ensure integrated delivery across all settings including the facilitation of comprehensive discharge planning and follow-up care.
- Develops an effective working relationship with the Patient and Family Counselor/Social Workers and UM Case Managers to engage the patient/family to collaborate advocate and problem solve, to support and enhance their functional ability while ensuring an appropriate and timely discharge plan.
- Counsels and assists members enrolled in care management with health-related social determinants, and financial, emotional, and social issues.
- Provides intervention and/or community linkage for patients and families who are experiencing significant emotional, social, environmental, or financial stress due to hospitalization, acute or chronic illness, and/or who need help in meeting their continuing care needs.
- Provides assessment of member’s behavioral health, medical and psychosocial needs and develops care plan with goals appropriate to the assessment findings.
- Provides members and caregivers education on community resources, facilitates referrals as appropriate, and monitors outcomes of referrals.
- Identifies and manages difficult cases, utilizing problem-solving techniques.
- Monitors patient and family/caregiver functional and psychosocial status and advocates for patient needs. Completes consultation requests made via referrals from CM RN Health Advisor, Healthcare Coordinators, pharmacists, or other eligible sources in a timely manner
- Ensures patients and families have access to prescription, durable medical equipment (DME) and other services as identified.
- Contributes to problem solving within the team through communication, collaboration, data collection, obtaining consensus and evaluating outcomes of treatment options to include tracking patient progress towards care plan goals and revising the care plan as indicated.
- Advocates for patients to optimize their health care needs including but not limited to safety, physical, legal, and financial well-being.
- Participates in the clinical outcomes measurement to include the identification of strategies that promotes population health. Actively participates as a member of the collaborative care team
- Demonstrates commitment to organizational and team success by maintaining attendance and productivity standards
- Provides thorough, timely, and appropriate documentation, in accordance with professional standards, in care management system.
- Maintains confidentiality of member’s records, maintains reasonably regular, punctual attendance consistent with OFP policies, the ADA, FMLA and other federal, state and local standards.
Other Related Functions:
- Provides clinical treatment interventions under the supervision of the Licensed Clinical Social Worker, to include facilitating patient’s psychosocial adjustment along the continuum of care and transition to the next level of care.
- Demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served though knowledge of the principles of growth and development over the life span.
- Demonstrates awareness of the medical/ legal issues patient rights and compliance with standards of regulatory and accrediting agencies.
Education and Experience Required:
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Master’s Degree in Social Work or related field
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At least 3 years of Social Work experience, preferably in a healthcare setting
Experience
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Competent in the provision of medical social work, including evaluation, assessment, and care planning
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Comprehensive knowledge, and understanding of, the impact of psychosocial factors on illness
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Possess excellent verbal and written communication skills
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Ability to work autonomously and as a member of a team
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Knowledge and experience with community-based resources
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Comfort interacting with patients and coworkers using webcam-enabled platforms like WebEx, Zoom, Skype, Go-To-Meeting, Face Time, or Google Duo.
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